Can A Preflight Checklist Facilitate Smoother Surgeries And Better Outcomes?

Stephen Barrett DPM FACFAS

As I was cruising to my office one morning at 9,500 feet above sea level, overflying the spectacular red rocks of Sedona, Ariz., an epiphany occurred for this month’s blog. The air was glassy smooth, virtually no traffic was on the radios and my usually quirky autopilot was functioning to perfection. This gave me time to reflect on my surgeries from the previous day.

Learning to fly and becoming a licensed pilot is by far the single best thing I have ever done, and has taught me so much more than aviation, which brings me to this blog. I do not think there is any surgeon in practice who would not agree that we could improve our surgical systems and outcomes by integrating some methods of operation commonly used in aviation.

It is equally serious stuff. Mess up in the aircraft and you may die. Mess up in surgery and the patient may end up with a really bad outcome, and an attorney will make you wish you were in a different country.

Surgery day started off great and we even had the fortune of having a student visit us for the day. I like those days when I can teach as well as perform the planned procedures. I always learn more when we are not just in the routine standard operating mode. With an observer present, we have to explain what we are doing. In effect, we are constantly checking our “gauges” during the case so to speak.

How many days have you spent in surgery recently when you were on “autopilot”? At the end of the day, you realize that everything went seemingly well and according to plan. However, you also realize that you really learned nothing that day and could not even recall what you did after dinner that same evening. Should we as surgeons operate more like pilots? Do you do what pilots normally do before every flight? Consider the following techniques to improve surgical outcomes.

Plan the upcoming mission (the planned surgical technique). Really focus on what you want to accomplish and make sure that all equipment needed is available and ready to go.

Check the weather (the medical status of the patient). Check the home status of the patient. Will he or she have someone to help out the first few days? Have you ever had to re-operate on a hallux valgus reconstruction because the patient fell a few days after surgery and displaced the fixation? I have. Perhaps we could prevent some of this by having our “team” check the domestic situation of the patient.

Plan and review the flight plan (review every scheduled case). You should check the medical records for signed consents and review your last progress note for the surgical consultation. Is the planned surgery taking all of the patient symptomatology into account? Do not be afraid to really re-examine the patient again on the morning of the surgery if there is any question about the complex pathology. We frequently find additional considerations, which are better to address “now” as opposed to “later.”

Preflight the airplane (check all the equipment before surgery). Check to make sure that every little piece of equipment is there at your center and is operating well. How many times is the case going well and then you realize you do not have the right saw blade or other minor piece of equipment? Redundancy is good and I have a huge black Pelican case that has a duplicate of almost everything (blades, scopes, etc.) I use. I rarely have to pull anything out but this system of organization can save you if you operate in different places. Make sure to enlist the surgical techs on your team. They can help so much.

Emphasizing The Value Of A Post-Op Debriefing

Debrief your mission (all good pilots review the flight they just completed and critique their own performance). What could I have done better during those cases? Could I have positioned the patient a little differently, which would have made my surgical exposure easier and decreased the tourniquet time? All of these seemingly insignificant little things add up to huge factors for our pursuit of the ultimate patient outcome.

I want to thank my residency director Dr. Edward M. Jacquet, a real aviator and former military fighter pilot, who is an extraordinary surgeon. I may not have gotten a lot of things that he was trying to convey at the time of my training but now, many years later, I really do understand.


Excellent article Dr. Barrett. The "pre-flight" checklist was emphasized to me a great deal in residency and I try to instill this in the residents I teach as well. You MUST do this before, during and after your surgeries. It will make you a better clinician and a better surgeon.

Every case is different. Even if you're technically doing the same procedure. I'm glad to know that others do this as well.

Great concept. You should read the book "Why Hospitals Should Fly," it takes this concept a bit further.

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